subject: error prone profile - wisconsin department … · the epp project only focuses on the...

State of Wisconsin Governor Scott Walker

TO: Income Maintenance Supervisors Income Maintenance Lead Workers Income Maintenance Staff W-2 Agencies Workforce Development Boards Job Center Leads and Managers Training Staff Child Care Coordinators FROM: Shawn Smith, Bureau Director Bureau of Enrollment Policy & Systems Division of Health Care Access and Accountability

DHS OPERATIONS MEMO

No: DHS 14-38 DATE: 9/15/2014 FS MA BC+ SC CTS FSET

SUBJECT: Error Prone Profile EFFECTIVE DATE: September 29, 2014 PURPOSE: The purpose of this Operations Memo is to announce changes in CARES Worker Web (CWW) to automate the process for identifying Error Prone cases and tracking the worker actions taken on those cases. BACKGROUND: On September 20, 2013, Governor Scott Walker directed the Department of Health Services (DHS) to evaluate and implement strategies that will strengthen fraud prevention in the state's public assistance programs. This strategy called for developing functionality in Cares Worker Web (CWW) to identify error prone cases and alert the worker prior to confirmation of benefits. A tracking system for savings attributed to the Error Prone Profile (EPP) process is also included in this update. The savings will be stored outside of CWW but can be accessed for ad hoc reports and future Income Maintenance Management Reports (IMMR).

DEPARTMENT OF HEALTH SERVICES Secretary Kitty Rhoades

1 West Wilson Street P.O. Box 7850

Madison, WI 53707-7850 Telephone: (608) 266-9622

FAX: (608) 266-7882 www.dhs.wisconsin.gov

OM 14-38 of 23 The Error Prone Profiles (EPP) will be selected with the following principles in mind:

• Profiles that would catch the most egregious and frequent errors • Profiles that would utilize information available in CWW (as opposed to utilizing

information outside of CWW) • Profiles that may prevent intentional (fraud) or unintentional errors by customers or

workers • Profiles that would be meaningful to IM workers and not result in a large number of false

positives NEW PROCESS: The fraud prevention strategies and processes currently in place for consortia and tribal agencies are not changing. The EPP project only focuses on the automated detection of three EPPs. Agencies must continue to maintain their own processes specified in their Fraud Plans for identification and follow up for EPPs not identified by CWW. EPPs that are detected by the system will not necessarily require Front-End Verification (FEV) or a fraud investigation. Rather, when the system identifies an EPP on a case, workers are expected to apply extra scrutiny to the existing verification process and document their actions. These cases may require additional verification or investigation prior to confirmation of benefits. If an EPP detected by the system warrants more extensive verification or appears suspicious, workers should refer the case for FEV or fraud investigation. When a worker runs eligibility on a case in Intake or Review mode, the EPP process evaluates the case information to detect potential errors. If potential errors are detected on a case, they are displayed on the Eligibility Run Results page in the EPPs Detected section along with the eligibility results. Workers are expected to review the potential error immediately and take additional actions toward resolving the error. In some instances, workers may need to request additional clarification from the customer. In other instances, the worker may simply realize that a data-entry mistake (worker or customer) has caused the information to be inaccurate or suspicious. When possible, the worker should resolve the potential error prior to confirmation of benefits. If an EPP detected by the system warrants more extensive verification or appears suspicious, workers should refer the case for FEV or Fraud Investigation. When a potential error is referred for FEV or Fraud Investigation, the worker will document this on the Potential Error Details page and the process of tracking the potential error ends in CWW. Any subsequent tracking of the referral is done in the Benefit Recovery (BV) subsystem.

Note: Even when a potential error is referred for FEV or Fraud Investigation, the agency should continue to adhere to application timeliness rules.

To encourage the documented resolution of potential errors prior to confirmation of benefits, CWW does not permit a program to be confirmed open, if there is one or more unresolved potential errors related to the program (with the exception of Deferred Potential Errors). When a potential error is detected, CWW determines which programs are "affected" by the EPP and confirmation for those programs is withheld.

OM 14-38 of 23 Due to processing deadlines and other factors it may not always be practical to resolve the potential error prior to the confirmation of benefits. In those instances, the case worker can defer the resolution of the potential error and confirm benefits immediately. However, the potential error is not completed until the worker records a resolution. For example, it may not be possible to resolve an error prior to issuing Expedited FoodShare benefits making it necessary to Defer Resolution Post Confirmation. All potential errors are tracked on the IM Workload Dashboard, from the moment of detection until the potential error is resolved. Based on agency preference, Potential Error Work Items are assigned to either the Primary Worker or the worker currently running eligibility. An e-mail was sent to the IM agencies from the DHS CARES Call Center asking for each agency’s preference. If no response was received, the default assignment will be set to the Primary Worker. This preference may be updated at any time. A request to do so should be sent to the DHS CARES Call Center. CARES/CWW: CWW will be updated to identify, at Intake and Renewal, the following three EPPs: QUESTIONABLE INCOME AND/OR EXPENSES: These are cases that may have questionable income based on either of the following conditions:

• Expenses exceed income. • Total income has remained the same for an extended period of time.

UNRESOLVED DISCREPANCIES: These cases may have inaccurate or unreported income based on the presence of unresolved State Wage Information Collection Agency (SWICA), Unemployment Insurance Benefits (UIB), State Online Query Internet (SOLQI) or Prisoner Match discrepancies. IPV/OVERPAYMENT HISTORY: CARES will identify cases that include members who have a history of Intentional Program Violations (IPV) or overpayments. CWW will look for the three EPPs when a case is in “Intake” or “Review” mode. In “Review” mode, the flags will not be set for the “Questionable Income and/or Expenses” or the “IPV/Overpayment History” EPP if those EPPs have been set for the case in the prior nine months. If the case is in review mode for one program only and there are other open programs on the case, the EPP will flag on all applicable programs of eligibility. If there is a new program added to an already open case, the EPPs will not be set on the case.

OM 14-38 of 23 ELIGIBILITY RUN RESULTS PAGE: The Eligibility Run Results page displays the potential errors that are flagged on the case under the “Error Prone Profiles Detected” section. Clicking on the magnifying glass will take you to the Potential Error Details page.

OM 14-38 of 23 POTENTIAL ERROR DETAILS PAGE: The Potential Error Details page provides the worker with information regarding the error and options to resolve it. It can also be accessed from the the Potential Error Listing page, and the Information Bar.

OM 14-38 of 23 ERROR PRONE PROFILE EXPLANATION SECTION:

The EPP Explanation Section provides a high level description of the EPP that has been flagged on the case including a checklist of actions workers can perform for resolution.

• Error Prone Profile: A general description of the EPP. • Process Checklist: Each EPP type will have a unique list of resolution procedures to

assist the worker in researching the cause of the potential error. Workers are expected to check off the steps they used to research the case. Responses to these check boxes will be saved.

POTENTIAL ERROR DETAILS SECTION:

The Potential Error Details Section provides detailed information regarding the potential error flagged on the case:

• Potential Error ID: This value identifies the unique error ID number associated to the potential error flagged on the case.

• Last Updated: The date when the Potential Error Details Page was last updated. • Initially Detected Date: The date when the potential error was first detected on the case. • Initially Detected By: The worker’s ID who ran eligibility when the potential error was first

detected on the case. • Resolution Status: This value indicates the resolution status of the potential error. • Meets Criteria: This value represents whether the case currently meets the criteria of the

EPP. For example, on a case with expenses exceeding income, a worker makes a change to the income on the case so that the expenses no longer exceed the income. When the worker reruns eligibility, this field will now show that the case no longer meets the criteria for this profile.

OM 14-38 of 23

• Originally Affected Programs: Open or Pending Programs on the case that were

affected when the potential error was initially detected. • Currently Affected Programs: Open or Pending Programs on the case that are currently

affected by the potential error. • Profile Previously Flagged: This edit will appear only if the Error Prone Profile has been

previously flagged on the case. The edit will display the following text: "This potential error has been previously detected on the case."

WHAT WOULD YOU LIKE TO DO? SECTION:

Workers must document the actions taken to resolve the issue prior to confirmation of benefits by choosing the action taken from the drop down menu and noting additional information in the Potential Error Comments Sections. How workers resolve the error will depend on the type of error and the need to issue timely benefits. On some cases, resolving the issue may consist of confirming the benefits and referring the case to the fraud unit. The “What would you like to do?” section provides four options to process the potential error. All of the options, with exception of the “Save Checklist/Comments” option, will track the resolution of the potential error by updating the Resolution Status shown in the Potential Error Details Section. Save Checklist/Comments This option is selected by default whenever a worker navigates to the Potential Error Details page. This option should be used when the worker wants to save the current status of the error checklist and/or any error comments that might have been entered in the comments section. Waiting for Customer Information This option should be selected when workers are waiting for information from the customer necessary to resolve the potential error. Once this option is selected it will become ‘read only’. Resolve This option is selected when the worker has completed the research and resolved the potential error. When recording an error resolution, workers are also required to enter the following information in addition to an Error Comment:

OM 14-38 of 23 Action Taken: Indicates the action taken by the worker. The choices for “Action Taken” that appear in the dropdown list will vary by the type of profile. Values will be provided in Process Help. (PH) Reason: Captures the reason the action was taken. The choices for “Reason” that appear in the dropdown list will vary by Profile and Action Taken. Values will be provided in PH. Other: This field will be enabled when the “Other” option is selected as the ‘Reason’. The worker must enter text in this field when it is enabled. Root Cause for Potential Error: This captures the cause of the EPP flagged on the case as well as additional details concerning the reasons for the worker’s actions. The choices for Root Cause that appear in the dropdown list will vary by Profile, Action Taken and Reason. Values will be provided in PH. Defer Resolution Post Confirmation: This option should be selected to defer the resolution of a potential error in order to process the application timely or due to lack of sufficient information to resolve the error. Once this option is selected and the page is saved, this option will become ‘read only’. If the worker defers the resolution of a potential error, the ‘Meets Criteria’ indicator will not change even if subsequent changes are made to the case. However, the worker would be able to choose other options on the page. POTENTIAL ERROR COMMENTS SECTION:

The Potential Error Comments Section is used to enter comments to document research, steps taken, and manual reassignment or escalation of the potential error resolution. A comment will be required for every workflow radio option selected, with exception to the ‘Save Checklist/Comments’ option.

OM 14-38 of 23 POTENTIAL ERROR LISTING PAGE:

When searching a case for any EPPs flagged on a case, workers will be able to navigate directly to the Potential Error Listing page from the Navigation Menu. This page displays all the potential errors on the case regardless of their status or if they continue to meet the criteria. On the Potential Error Listing page workers may search by a Detected Date Range and click “Go” to display the search results. Clicking on the magnifying glass next to the EPP will take the worker to the Potential Error Details Page.

OM 14-38 of 23 CONFIRM ELIGIBILITY PAGE:

To ensure the documented resolution of potential errors prior to confirmation of benefits, CWW will not allow a program to be confirmed open if there are one or more unresolved potential errors related to the program (with exception to deferred potential errors). When a potential error is detected, CWW determines which programs could potentially be affected by the EPP and those programs cannot be confirmed.

OM 14-38 of 23 CASE SUMMARY PAGE

OM 14-38 of 23 After running eligibility, if an EPP has been identified on a case, workers will see a message displayed on the Case Summary page indicating there are one or more unresolved Potential Error Profiles detected on the case. Navigate to the Potential Error Listing page for more information.

The following information gives a detailed description of the conditions that must be met and the programs affected by each of the three EPPs. IPV/OVERPAYMENT HISTORY:

The flag for the IPV/Overpayment History EPP will be set when:

• Any individual currently associated with the case who has had at least one IPV

(FS, CC or W-2) recently, or, • Excessive overpayment claims associated with all individuals listed on the case

in the last five years, counting only claims from Client Error (CE) or Intentional Violation (IV).

The flag for this EPP will be set for the following programs of assistance at Intake and Renewal as long as the program remains Open or Pending for the recurring month as long as the flag for the same EPP was not set in the prior nine months.

OM 14-38 of 23

• FoodShare (FS) (including expedited benefits), • Child Care (CC), • BadgerCare Plus (BC+), • Medicaid (MA) for Elderly, Blind or Disabled (EBD) or Long Term Care MA (LTC), • Medicare Premium Assistance (MPA), • Institutional MA and • Caretaker Supplement (CTS)

The flag for the EPP will not be set for Family Planning Only Services (FPOS) or Wisconsin Works (W-2). QUESTIONABLE INCOME/EXPENSES:

The Questionable Income/Expenses EPP flag will be set when:

Total Expenses exceed Total Income and the case has a Pending or Open FoodShare budget for the recurring month. Or Total Budgeted Income for FoodShare has been exactly the same for an extended period of time and the Eligibility Status is Pending or Open.

The flag for this EPP will be set for the following programs of assistance at Intake and Renewal as long as the program remains Open or Pending for the recurring month as long as the flag for the same EPP was not set in the prior nine months.

• FS (including expedited benefits), • BC+, • EBD/LTC MA

The flag for this EPP will not be set for Transitional FoodShare (TFS) Assistance Groups (AGs), FPOS, W-2, MPA, Insitutional MA, CC and CTS.

OM 14-38 of 23 UNRESOLVED DISCREPANCIES:

The Unresolved Discrepancies EPP flag will be set when the case has two or more unresolved discrepancies that are more than 45 days old. The flag for this EPP will be set for the following programs of assistance at Intake and Renewal as long as the program remains Open or Pending for the recurring month as long as the flag for the same EPP was not set in the prior nine months. If the unresolved discrepancies are only SWICA discrepancies, the flag will be set for the programs for which the discrepancies were created. If one of the unresolved discrepancies is Prisoner, SOLQI or UIB the flag will be set for:

• FS (including expedited), • CC, • BC+, • EBD/LTC MA, • MPA, • Insitiutional MA, • CTS and • FPOS.

The flag will not be set for W-2.

OM 14-38 of 23 INTEGRATION WITH THE DASHBOARD: Potential errors will be displayed on the Workload Dashboard. As with the current design of the Dashboard, the information is initally shown with all of the counts “collapsed” and summarized for a given worker, team, county or consorita. Like Applications and SMRFs, the counts for Potential Errors will be in the appropriate column relative to their due date. These Work Items will have a due date of 20 days from the initial detection date of the EPP.

Like Applications and SMRFs, workers can drill down to see details for Potential Errors. Here, they can differentiate their work by the status of the Potential Error. A worker can drill down even further to the profile level In the following screenshot, the worker can see nine Potential Errors for which he or she deferred resolution until after confirmation. The worker confirmed the benefits, but still must research and complete the work associated with the Potential Error. Because these two items aren’t waiting for information from the applicant/customer, the worker can act on it right away.

Potential Error Work Item Statuses

• Unresolved • Unresolved – Waiting for Customer Information • Deferred Resolution • Deferred – Waiting for Customer Information • Resolved – Waiting for Confirmation

OM 14-38 of 23 Work Item Status Process Chart

Work Item Status

What triggers the status? Who is assigned to this status?

Status Due Date

What page in CWW should this status link to?

1 Unresolved A potential error work item is created for every potential error flagged once a worker runs current eligibility on a case. 'Unresolved' is the default status of the work item at creation.

Agency preference: Primary Worker or worker that ran eligibility

20 days from the detection of the work item.

Case Summary

2 Unresolved – Waiting for Customer Information

Worker selects the “Waiting for Customer Information" workflow option on the Potential Error Details page.



Case Summary

3 Deferred Resolution

Worker selects the "Deferred Resolution Post Confirmation" workflow option on the Potential Error Details page.


No change from prior status20 days from the detection of the work item.

Case Summary

4 Deferred – Waiting for Customer Information

Worker selects the "Deferred Resolution Post Confirmation" workflow option after having selected "Waiting for Customer Information" on the Potential Error Details page or vice-versa.



Case Summary

5 Resolved – Waiting for Confirmation

Worker selects the "Resolve" workflow option on the Potential Error Details page.



Case Summary

6 Completed Worker confirms all 'Currently Affected' programs on a resolved potential error without deferring it.



Case Summary

7 Completed – Deferred

Worker selects the "Resolve" workflow option on the Potential Error Details page for a deferred potential error.



Case Summary

48 Auto-completed All "Currently Affected" programs denied/closed on a potential error in "Resolved – Waiting for Confirmation status" after running current eligibility.



Case Summary

OM 14-38 of 23 Work Item Search The Potential Error Category has been added to the Work Item Search page. The search functionality has not changed.

OM 14-38 of 23 Work Item Search Results The magnifying glass on the Work Item Search Results page is now a History Icon, which will navigate you to the Work Item Details page.

Work Item Reassignment The Potential Error Work Item can be reassigned via the reassignment page. The functionality of this page has not changed. Potential Error Work Item Lifecycle

Potential Error

Flagged on Case

1 2 3 4

Unresolved

Unresolved – Waiting for

Client Information

Deferred Resolution

Deferred – Waiting for

Client Information

Resolved – Waiting for

ConfirmationCompleted

Completed - Deferred

Auto-Completed

OM 14-38 of 23 ADDRESS SEARCH: CWW will be enhanced with an additional tool to help workers in the detection of potential errors and fraud. The Address Search Tool will allow agencies to search for cases by address to find other open cases that have the same household or mailing address.

• Address search may be used at worker discretion. • Address searching will compliment activities already completed by IM workers. • Identification of cases with the same address may impact household composition and/or

countable income, which would result in reduced benefits. SEARCH CRITERIA PAGE

OM 14-38 of 23 One way to search is by using the new Address Search segment on the Search Criteria page in CWW. The purpose of this page is to validate the address entered in the Search Criteria to determine if any cases have a matching Household or Mailing address. Using this search function will assist workers in clarifying household composition and preventing potential errors or fraud. For example: A search is done for an address reported on a new application and three open cases are found. In one case a husband and wife are listed, and the other two cases list two adult children under 22 years old. The household is receiving total FoodShare benefits of $659 between the three cases. Because of relationship rules, the two adult children should be part of the parent’s assistance group. When the three cases are combined, the correct benefit for the household is $48, which is a savings of $611 a month. ADDRESS SEARCH CRITERIA PAGE

The entered address will be run through “Finalist” web service. The worker has three options:

1. Accept the Post Office suggested address, 2. Override the Post Office suggested address, or 3. Edit the address and Resubmit it (it will run through “Finalist” again).

OM 14-38 of 23 ADDRESS SEARCH RESULTS PAGE

Search Results (open or recently closed/denied cases within 30 days) which have the same household address and/or same mailing address as the search address will be displayed. Both Household Address and Mailing Address matches will be available at the same time. Confidential cases will be excluded unless the worker who is searching has a security clearance of 90 or higher. Workers with security level of 50+ will be able to click the “Search by Zip+4” ONLY if the original search criteria included the Zip+4. Otherwise, this option will not show.

After selecting a case from the Search Results page, the worker will be taken to the Case Summary page for that case. They can click the green “Address Search Results” button to return to the results listing. This button will remain active as long as the worker is in the context of the case.

OM 14-38 of 23 Another way to do an address search is from the General Case Information Page.

Workers can click on the “Find Matching Cases” button in the Household Address section or the Mailing Address section. The mailing address button will be disabled if there is no mailing address. These buttons will only be enabled after the address has been run through “Finalist” and the address has been verified as accepted or overridden. Once the address goes through “Finalist”, the worker will have to return to the General Case Information page to click on the “Find Matching Cases” button. If the worker changes anything in the address fields, the address will have to be run through “Finalist” again before the button will be enabled again.

OM 14-38 of 23 ADDRESS SEARCH RESULTS PAGE

Clicking the “Find Matching Cases” buttons will take the worker to the Address Search Results page, the case number of the original case is included as a hyperlink. Clicking the link will take the worker back to the Case Summary of that case. CONTACTS: BEPS CARES Information & Problem Resolution Center *Program Categories – FS – FoodShare, MA – Medicaid, BC+ – BadgerCare Plus, SC – SeniorCare, CTS – Caretaker Supplement, FSET – FoodShare Employment and Training. DHS/DHCAA/BEPS/DT

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